IS THERE A PROTOCOL FOR THAT?

I recently attended the American Academy of Podiatric Practice Management (AAPPM) resident’s workshop seminar.  I had the usual “tools” with me to begin what I thought would be the usual conference: the quintessential cup of coffee, my trusty notebook and pen, and being the typical female, my winter sweater for the predicted temperature flux in the prototypical hotel conference room.  However, this workshop seminar was unlike any I have attended in the past.  I like to say I am a resident “veteran” of the annual podiatric conferences like ACFAS and typically like to contribute research in the form of posters or presentations each year.  Yet, I can honestly say that from the moment I sat down at the standard Marriott conference room table on August 26th in Pittsburgh, I knew this would be no ordinary workshop and my pen didn’t stop writing until long after the last speaker stopped talking.  

As a third year resident, I am obviously on the lower end of the spectrum in terms of practice experience and as such, am probably not qualified to write an article under the section of “practice management pearls.”  That being said, I feel the obligation to disseminate the advice of specific members of our community who took their time during the AAPPM workshop to provide information applicable not only to those just beginning their practices but also to those with years of experience under their belt.  At all conceivable venues like the lecture podium, the dinner table, the bar, the hallway and yes, even the bathroom, Dr. Hal Ornstein; Dr. John Guiliana; Jeffrey Lafferty, JD and Mike Crosby all spent an innumerable amount of time providing what has been long labeled, practice management pearls.  I have chosen just one of those pearls to expound on here. 

Generally speaking, it has been proven that implementation and adherence to guidelines and protocols can reduce health-care costs up to 25%.1,2With the ever present rising cost of health, today’s evidence-based medicine has given rise to an increasing number of medical practice protocols.  The field of nursing provides a quality example of how these protocols are implemented and managed.  Moreover, one need only visit the website of any major hospital system in the United States to feel overwhelmed by the information provided on hospital protocols, clinical pathways and/or guidelines.  If the entire medical community can obviously benefit from such models, why can’t the lower extremity specialist?  The advantages of protocol implementation stem from increased time efficiency, clarity of treatment and ease of reproduction and may be gleaned by the sole practitioner or the multi-specialty group practitioner.      

Protocol models may be developed in a variety of ways, but typically result from original knowledge, textbooks, journal articles, data collection (in various formats) and expert opinions.  Of course there should be protocols for situations like acute chest pain or acute deep vein thrombosis, but what about heel pain or a neuroma?  I don’t think anyone would debate the fact that guidelines like those published as the American Cardiac Life Support represent the paragon of protocols and differ greatly in a number of ways from the rough guidelines established for a diagnosis like plantar fasciitis.  That being said, the pearl to be garnered here is twofold:

1.)     In the broadest definition of protocol, the advantages obtained with implementation have already been highlighted by the vast success of the medical community’s incalculable guidelines. 

2.)     The parameters acknowledged for the various lower extremity diagnoses in an office setting are malleable and can be formatted to the individual physician’s practice and opinions. 

This translates to surveying one’s practice and establishing the top 5 most common reason for patient visits.  For example, heel pain is most likely the number one reason why people present to the podiatrist.  Creating a protocol for plantar fasciitis treatment can be tailored to the particular physician’s style of treatment and would include the first visit treatment options and patient education, second visit treatment modalities and so on.  Not only would the patient education be standard, but also the treatments rendered at each stage virtually the same for each patient. This approach streamlines the office staff for each patient being seen for “heel pain.”  Consequently, expedition of treatment and patient education results as the staff knows on patient’s first visit for “heel pain”, brochures are dispensed as well as an injection verses the patient with chronic heel pain who returns after 6 months of conservative care.  There are obvious exceptions to all standardized protocols, but for the majority of the patients presenting, a protocol may be implemented.  Certainly one would not want their patients to feel as if they were on a Detroit Ford assembly line with parts being added as they came and went, but I think the productivity, quality and reliability of Porsche is a nice analogy to the effectiveness of how fine-tuned your office will become when dealing with the diagnosis that could fall under the application of a protocol.  

Amy Duckworth is a third year resident at St. John North Shores hospital in Detroit Michigan and member of The American Academy of Podiatric Practice Management.  She can be reached at amyduckie@sbcglobal.net. 

REFERENCES 

Clayton P, Hripsak G.  Decision support in health care, Int J of Biomedical Computing.  1995 39:59-66.

Balser M, Cotell O, van Croonenborg J, Duelli C, et. Al.  Protocure: supporting the development of medical protocols through formal methods, www.protocure.org. 


Amy L. Duckworth, DPM